Telemedicine

1
Telemedicine

• Thomas Nesbitt, M.D., M.P.H.
• Associate Vice Chancellor, Strategic Technologies
  and Alliances
• Director, Center for Health and Technology
• Chief Scientist, CITRIS
• University of California, Davis

2
There is a growing expectation that advanced
information technology will transform our health
care system.
3
The explosion of new knowledge and information in
the health sciences is ironically creating
greater disparities in the quality of health care
services.
4
Advances in telecommunications and advanced
information technologies can help to redistribute
health care information and expertise to where
and when it is needed
5
One of the problems is that we are applying these
new technologies to a old model of health care
delivery instead of using technology to
facilitate a change in the models of care
6
These technologies can help facilitate a new,
more efficient model of care across the economic
and geographic spectrum.
7
Access to current medical science for the next
clinical decision
8
Elements of a Distributed, Technology Enabled
Health Care System

• Care at Home and Chronic Disease Management
• Ambulatory, Clinic and Community Care
• Hospital Care

9
Care at Home and Chronic Disease Management
10
Traditionally, we have used the same process of
care for managing chronic disease as we have used
for acute illnesses
11
Home Telehealth VA Case Example

• Today
• 16,000 patients enrolled in daily home
  telehealth with Health Buddy
• Deployed in 120 clinical sites
• Over 100 programs for 30 chronic conditions

February 2006
12
Care Management Process with the Health Buddy
System
Scripted messaging, monitoring and reporting
platform
Education, monitoring and feedback at home
Personalized, remote care management and support.
13
VA Outcomes 2002 Telehealth Reduces Inpatient
Utilization

• 40 reduction in ER visits
• 63 reduction in hospital admissions
• 63 reduction in hospital bed days of care
• 64 reduction in nursing home admissions
• 88 reduction in nursing home bed days
• Significantly improved Quality of Life SF36V

1-Year Telemedicine Care Coordination
Demonstration
Published in Disease Management Volume 5,
Number 2, 2002.
14
VA Outcomes 2005 Telehealth Improves Clinical
Outcomes

• Hospitalizations declined from 630 inpatient days
  pre to 122 during intervention period
• Bed Days Of Care fell from 8.63 to 1.65 (p lt
  0.001)
• Blood Pressure 129/73 to 119/69 (p lt 0.05)
• Weight 196 to 192 (p lt 0.01)
• Shortness of Breath 0-10 Scale 4.0 to 2.7 (p
  0.02)
• ACE Inhibitor Avg Daily Dose 24mg/d to 35 (p lt
  0.01)
• ?-Blocker Avg Daily Dose 84 mg/d to 94 (p
  0.05)

1-Year Telemedicine Care Coordination
Demonstration
Published in Telemedicine and e-Health Volume
11, Number 1, 2005.
15
In an ideal situation, complete information about
patient would be available to health care
providers continuously and captured in a database
16
Remote Care Convergence of Sensors and Jewelry
Language Xlater
Body Aggregator
Pulse Oximetry
Blood Press.
Cell phone as gateway
Fashion addresses the stigmata of
care Patients bearing greater costs of
care Self care is a real possibility Approaches
that address quality, productivity, efficiency
and timeliness are needed.
Courtesy Paul Wright
17
Heart Disease Example

• Traditional process
• Episodic visits
• Recall by patient for episodes
• Physiologic data taken in the MD office
• Body sensors
• Heart Rate, Blood Pressure, oximetry, temperature
• Aggregates to mobile phone program
• Program has critical values, rings phone, sends
  data and message to office personnel
• Interaction trends between parameters may also
  trigger earlier alarm (e.g. Slightly falling BP,
  with increase HR, with decrease in blood O2)
• Data captured in database for office visits with
  event diary

18
Eric Topol MD
19
Care in the Ambulatory Setting
20
Telemedicine

• Interactive healthcare over distance using
  technology
• Telemedicine brings the expertise of a
  specialist to the point of care
  and allows that expertise to be customized to
  that patient

21
Why Telemedicine Makes Sense for Rural Health Care
22
Rural Teleophthalmology
23
Select Focus Areas In Outcome Studies

• Dermatology
• Diagnosis agreement high comparing (differential)
  diagnosis via telemedicine and clinic-based
  examiners (Whited, 1999, 2001 Wootton, 2000)
• Teledermatology consults resulted in 76
  treatment changes, 52 diagnostic changes from
  those of the referring general practitioner
  (Lamminen, 2000)
• Clinical outcomes in skin cancer management via
  SF TM as measured by times to diagnosis and to
  surgical treatment can be comparable, if not
  better than, conventional management ( Hsiao J.
  et al. J Am Acad Dermatol 2008)

24
Select Focus Areas In Outcome Studies

• Clinical Consultations
• Psychiatry
• Diagnosis and management plan agreement high
  between in person and telemedicine (Elford, 2000
  Ruskin, 1998)
• Psychiatric consultation and short-term follow-up
  can be as effective when delivered by
  telepsychiatry as when provided face to face.
  O'Reilly R, Bishop J, Maddox K, Hutchinson L,
  Fisman M, Takhar J. Psychiatr Serv. 2007
  Jun58(6)836-43
• Changes in diagnosis, treatment, and clinical
  improvement among patients receiving telemedicine
  consultations Marcin JP, Nesbitt TS, Cole SL,
  Knuttel RM, Hilty DM, Prescott PT, Daschbach MM.
• Telemed J E Health. 2005
  Feb11(1)36-43.

25
Can lead to more cost effective models

• Having the right science at the right time at the
  right place which can avoid waste
• Efficiently providing correct amount of expertise
  needed to make the next evidenced based clinical
  decision for the patient
• Minimizing the time and effort of the patient,
  the referring provider and the specialist
• Minimizing duplications of services

26
Hospital Based Telemedicine
27
Emergency Room Telemedicine
28
Emergency Medicine Outcomes

• Efficacy of site-independent telemedicine in the
  STRokEDOC trial a randomized, blinded,
  prospective trial.
• Meyer BC, Raman R, Hemmen T, Obler R, Zivin JA,
  Rao R, Lancet Neurol. 2008 Sep7(9)787-95.
• Tele-stroke care -222 patient cases showed
  telemedicine evaluation led to better
  decision-making than telephone consultations
• A review of the evidence for the use of
  telemedicine within stroke systems of care a
  scientific statement from the American Heart
  Association/American Stroke Association.
• Stroke. 2009 Jul40(7)2616-34. Epub 2009 May 7

29
(No Transcript)
30
Inpatient Pediatric and Adult Critical Care
31
Remote Intensive Care Model

• Control room type model - video and sensors
• Continuous monitoring of many patients in several
  different locations
• Improves clinical outcomes
• Improves access to information
• Standardizes care
• Reduces costs (one intensivist for several sites)
• Rosenfeld BA et al. Intensive care unit
  telemedicine alternate paradigm for providing
  continuous intensivist care. Crit Care Med. 2000
  Dec28(12)3925-31.

32
UC Davis PICU Model

• Telemedicine consultations on critically ill
  pediatric patients in a rural adult ICU
• Mortality and length of stay outcomes were
  equivalent to PICU benchmarks
• High satisfaction with the quality of care among
  physicians, parents and nurses
• Marcin J. et al. Use of telemedicine to provide
  pediatric critical care inpatient consultations
  to underserved rural Northern California. J
  Pediatr. 2004 Mar144(3)375-80.

33
One of the essential requirements for an
optimally functioning technology enabled health
care system and research network is widely
distributed broadband connectivity which is
reliable, with explicit quality of service (QOS),
security, privacy
34
The California Telehealth NetworkA digital
health care highway
35
FCC Rural Health Care Pilot Program

• Dedicated over 417 million for 69 pilot program
  networks
• Encourages regional broadband health care
  networks with connections to national backbones

UPDATE!
36
Consortium Members

• The Office of the Governor
• California Business, Transportation and Housing
  Agency (BTH)
• The California Emerging Technology Fund (CETF)
• The California Public Utilities Commission (CPUC)
• The California Department of Managed Health Care
  (DMHC)
• The California Telemedicine eHealth Center
  (CTEC)
• Rural Telehealth Networks
• The UC Office of the President
• University of California Davis Health System
• The Office of Statewide Health Planning and
  Development (OSHPD)
• California Health Human Services Agency (CHHSA)
• The Corporation for Education Network Initiatives
  in California
• The California Office of Emergency Services
  (OES) 
• The California Institute for Telecommunications
  and Information Technology
• The California Hospital Association (CHA)
• The California Health Foundation and Trust (CHFT)
  
• The California State Rural Health Association
  (CSRHA)
• The California Primary Care Association (CPCA)

37
FCC Rural Health Care Pilot Program Californias
Goals Summarized

• Goal 1 Create statewide broadband network
  dedicated to health care with explicit QOS,
  privacy and security
• Goal 2 Link the California Telehealth Network
  (CTN) to a national backbone
• Goal 3 Leverage and build upon recent
  investments in telehealth
• Goal 4 Utilize CTN for ongoing disaster
  preparedness training

38
Current Status of the CTN

• Award of 22.1M from FCC
• California Emerging Technology Fund (CETF)
  providing 3.6M for 15 match and start-up funds
• 5M commitment from United Health Care
• Letter of Agency process (completed)
• Original goal was 319
• Over 1000 locations represented in the received
  letters of agency
• USAC has qualified 863 sites
• RFP was posted on the USAC RHCPP web-site
• An award should be made in the next 15 days

39
FY 2007 Sites
40
Pilot 2009 Sites
4 to 14 3 to 4 2 to 3 1 to 2 1
41
Current Model
42
California Telehealth Network
43
The Value of the CTN in Technology Enable Health
Reform

• Represents 900 to 2000 health care anchor
  institutions that have already self-identified as
  being interested in technology solutions to
  health care
• Managed network, single point of contact, data
  collection and management on uses of broadband
• Subsidized broadband connectivity, expandable
  bandwidth on demand
• With ARRA, RECs and Prop 1D funding, equipment
  and training resources

44
How this all comes together

• All patients have a primary medical home and
  have fully portable EHRs
• All health providers able to exchange health
  information and connect to expertise via
  telemedicine
• Body sensors and home care are used for chronic
  disease management, falls prevention, monitoring
  the elderly, weight loss, etc.
• Data from sensors flow to EHRs and EHRs into
  accessible data repositories and disease
  registries
• New, more efficient delivery models are developed
  using these technologies